Spinal cord injuries
| ICD10 = , | ICD9 = | ICDO = | OMIM = | MedlinePlus = | eMedicineSubj = emerg | eMedicineTopic = 553 | eMedicine_mult = | MeshID = D013119 }} Spinal cord injury causes myelopathy or damage to white matter or myelinated fiber tracts that carry sensation and motor signals to and from the brain. Spinal Cord Medicine: Principles and Practice (2002) Lin VWH, Cardenas DD, Cutter NC, Frost FS, Hammond MC. Demos Medical Publishing Spinal Cord Medicine (2001) Kirshblum S, Campagnolo D, Delisa J. Lippincott Williams & Wilkins It also damages gray matter in the central part of the spine, causing segmental losses of interneurons and motorneurons. Classification The American Spinal Injury Association (ASIA) first published an international classification of spinal cord injury in 1982, called the International Standards for Neurological and Functional Classification of Spinal Cord Injury(ISNCSCI) and now, in its sixth edition, is still widely used to document sensory and motor impairments following SCI. It is based on neurological responses, touch and pinprick sensations tested in each dermatome, and strength of ten key muscles on each side of the body, including hip flexion (L2), shoulder shrug (C4), elbow flexion (C5), wrist extension (C6), and elbow extension (C7). Traumatic spinal cord injury is classified into five categories on the ASIA Impairment Scale: * A indicates a "complete" spinal cord injury where no motor or sensory function is preserved in the sacral segments S4-S5. * B indicates an "incomplete" spinal cord injury where sensory but not motor function is preserved below the neurological level and includes the sacral segments S4-S5. This is typically a transient phase and if the person recovers any motor function below the neurological level, that person essentially becomes a motor incomplete, i.e. ASIA C or D. * C indicates an "incomplete" spinal cord injury where motor function is preserved below the neurological level and more than half of key muscles below the neurological level have a muscle grade of less than 3, which indicates active movement with full range of motion against gravity. * D indicates an "incomplete" spinal cord injury where motor function is preserved below the neurological level and at least half of the key muscles below the neurological level have a muscle grade of 3 or more. * E indicates "normal" where motor and sensory scores are normal. Note that it is possible to have spinal cord injury and neurological deficits with completely normal motor and sensory scores. Dimitrijevic proposed a further class, the so-called discomplete lesion, which is clinically complete but is accompanied by neurophysiological evidence of residual brain influence on spinal cord function below the lesion. In addition, there are several clinical syndromes associated with incomplete spinal cord injuries. * The Central cord syndrome is associated with greater loss of upper limb function compared to lower limbs. * The Brown-Séquard syndrome results from injury to one side with the spinal cord, causing weakness and loss of proprioception on the side of the injury and loss of pain and thermal sensation of the other side. * The Anterior cord syndrome results from injury to the anterior part of the spinal cord, causing weakness and loss of pain and thermal sensations below the injury site but preservation of proprioception that is usually carried in the posterior part of the spinal cord. * Tabes Dorsalis results from injury to the posterior part of the spinal cord, usually from infection diseases such as syphilis, causing loss of touch and proprioceptive sensation. * Conus medullaris syndrome results from injury to the tip of the spinal cord, located at L1 vertebra. * Cauda equina syndrome is, strictly speaking, not really spinal cord injury but injury to the spinal roots below the L1 vertebra. One can have spine injury without spinal cord injury. Many people suffer transient loss of function ("stingers") in sports accidents or pain in "whiplash" of the neck without neurological loss and relatively few of these suffer spinal cord injury sufficient to warrant hospitalization. In the United States, the incidence of spinal cord injury has been estimated to be about 35 cases per million per year, or approximately 10,500 per year (35 * 300). In China, the incidence of spinal cord injury was recently estimated to be as high as 65 cases per million per year in urban areas. If so, assuming a population of 1.3 billion, this would suggest an incidence of 84,500 per year (65 * 1300). The prevalence of spinal cord injury is not well known in many large countries. In some countries, such as Sweden and Iceland, registries are available. About 450,000 people in the United States live with spinal cord injury (one in 670), and there are about 11,000 new spinal cord injuries every year (one in 30,000). The majority of them (78%) involve males between the ages of 16-30 and result from motor vehicle accidents (42%), violence (24%), or falls (27%). This is likely due to increased risk-taking behavior in men. The Effects of Spinal Cord Injury The exact effects of a spinal cord injury vary according to the type and level injury, and can be organized into two types: * In a ''complete injury, there is no function below the "neurological" level, defined as the lowest level that has intact neurological function. If a person has some level below which there is no motor and sensory function, the injury is said to be "complete". Recent evidence suggest that less than 5% of people with "complete" spinal cord injury recover locomotion. * A person with an incomplete injury retains some sensation or movement below the level of the injury. The lowest spinal cord level is S4-5, representing the anal sphincter and peri-anal sensation. So, if a person is able to contract the anal sphincter voluntarily or is able to feel peri-anal pinprick or touch, the injury is said to be "incomplete". Recent evidence suggest that over 95% of people with "incomplete" spinal cord injury recover some locomotory ability. In addition to a loss of sensation and motor function below the point of injury, individuals with spinal cord injuries will often experience other complications of spinal cord injury: * Bowel and bladder function is regulated by the sacral region of the spine, so it is very common to experience dysfunction of the bowel and bladder, including infections of the bladder, and anal incontinence. * Sexual function is also associated with the sacral region, and is often affected. * Injuries of the C-1, C-2 will often result in a loss of breathing, necessitating mechanical ventilators or phrenic nerve pacing. * Inability or reduced ability to regulate heart rate, blood pressure, sweating and hence body temperature. * Spasticity (increased reflexes and stiffness of the limbs). * Neuropathic pain. * Autonomic dysreflexia or abnormal increases in blood pressure, sweating, and other autonomic responses to pain or sensory disturbances. * Atrophy of muscle. * Superior Mesenteric Artery Syndrome * Osteoporosis (loss of calcium) and bone degeneration. * Gallbladder and renal stones. The Location of the Injury Knowing the exact level of the injury on the spinal cord is important when predicting what parts of the body might be affected by paralysis and loss of function. Below is a list of typical effects of spinal cord injury by location (refer to the spinal cord map to the right). Please keep in mind that while the prognosis of complete injuries are predictable, incomplete injuries are very variable and may differ from the descriptions below. Cervical injuries Cervical (neck) injuries usually result in full or partial tetraplegia (Quadraplegia). Depending on the exact location of the injury, one with a spinal cord injury at the cervical level may retain some amount of function as detailed below, but are otherwise completely paralyzed. * C3 vertebrae and above : Typically lose diaphragm function and require a ventilator to breathe. * C4 : '''May have some use of biceps and shoulders, but weaker * C5 : May retain the use of shoulders and biceps, but not of the wrists or hands.' * '''C6' : Generally retain some wrist control, but no hand function. * C7 and T1 : Can usually straighten their arms but still may have dexterity problems with the hand and fingers. C7 is generally the level for functional independence. Patients with complete injuries above C7 typically cannot handle activities of daily living and cannot function independently. Additional signs and symptoms of cervical injuries include: * Inability or reduced ability to regulate heart rate, blood pressure, sweating and hence body temperature. * Autonomic dysreflexia or abnormal increases in blood pressure, sweating, and other autonomic responses to pain or sensory disturbances. Thoracic injuries Injuries at the thoracic level and below result in paraplegia. The hands, arms, head, and breathing are usually not affected. * T1 to T8 : Most often have control of the hands, but lack control of the abdominal muscles so control of the trunk is difficult or impossible. Effects are less severe the lower the injury. * T9 to T12 : Allows good trunk and abdominal muscle control, and sitting balance is very good. Lumbar and Sacral injuries The effect of injuries to the lumbar or sacral region of the spinal canal are decreased control of the legs and hips, urinary system, and anus. Central Cord and Other Syndromes Central cord syndrome (picture 1) is a form of incomplete spinal cord injury characterized by impairment in the arms and hands and, to a lesser extent, in the legs. This is also referred to as inverse paraplegia, because the hands and arms are paralyzed while the legs and lower extremities work correctly. Most often the damage is to the cervical or upper thoracic regions of the spinal cord, and characterized by weakness in the arms with relative sparing of the legs with variable sensory loss. This condition is associated with ischemia, hemorrhage, or necrosis involving the central portions of the spinal cord (the large nerve fibers that carry information directly from the cerebral cortex). Corticospinal fibers destined for the legs are spared due to their more external location in the spinal cord. This clinical pattern may emerge during recovery from spinal shock due to prolonged swelling around or near the vertebrae, causing pressures on the cord. The symptoms may be transient or permanent. Anterior cord syndrome (picture 2) is also an incomplete spinal cord injury. Below the injury, motor function, pain sensation, and temperature sensation is lost; touch, proprioception (sense of position in space), and vibration sense remain intact. Posterior cord syndrome (not pictured) can also occur, but is very rare. Brown-Séquard syndrome (picture 3) usually occurs when the spinal cord is hemisectioned or injured on the lateral side. On the ipsilateral side of the injury (same side), there is a loss of motor function, proprioception, vibration, and light touch. Contralaterally (opposite side of injury), there is a loss of pain, temperature, and deep touch sensations. Causes Spinal cord injury can occur from many causes, including: * Trauma such as Car crashe whiplash, falls, gunshots, diving accidents, war injuries, etc. * Tumor such as meningiomas, ependymomas, astrocytomas, and metastatic cancer. * Ischemia resulting from occlusion of spinal blood vessels, including dissecting aortic aneurysms, emboli, arteriosclerosis. * Developmental disorders, such as spina bifida,etc * Neurodegenerative diseases, such as Friedreich's ataxia, spinocerebellar ataxia, etc. * Demyelinative diseases, such as Multiple Sclerosis. * Transverse myelitis, resulting from spinal cord stroke, inflammation, or other causes. * Vascular malformations, such as arteriovenous malformation (AVM), dural arteriovenous fistula (AVF), spinal hemangioma, cavernous angioma and aneurysm. Spinal cord injuries are most often traumatic, caused by lateral bending, dislocation, rotation, axial loading, and hyperflexion or hyperextension of the cord or cauda equina. Motor vehicle accidents are the most common cause of SCIs, while other causes include falls, work-related accidents, sports injuries, and penetrations such as stab or gunshot wounds. SCIs can also be of a non-traumatic origin, as in the case of cancer, infection, intervertebral disc disease, vertebral injury and spinal cord vascular disease. Men are at more risk for spinal cord injury than women. It has been observed that more than 80% of the spinal cord injury patients are men. Diagnosis A radiographic evaluation using a x-ray, MRI or CT scan can determine if there is any damage to the spinal cord and where it is located. A neurologic evaluation incorporating sensory testing and reflex testing can help determine the motor function of a person with a SCI. Management Modern trauma care includes a step called clearing the cervical spine, where a person with a suspected injury is treated as if they have a spinal injury until that injury is ruled out. The objective is to prevent any further spinal cord damage. People are immobilized at the scene of the injury until it is clear that there is no damage to the highest portions of the spine. This is traditionally done using a device called a long spine board and hard collar. Once at a hospital and immediate life-threatening injuries have been addressed, they are evaluated for spinal injury, typically by x-ray or CT scan. Complications of spinal cord injuries include neurogenic shock, respiratory failure, pulmonary edema, pneumonia, pulmonary emboli and deep venous thrombosis, many of which can be recognized early in treatment and avoided. SCI patients often require extended treatment in an intensive care unit. Techniques of immobilizing the affected areas in the hospital include Gardner-Wells tongs, which can also exert spinal traction to reduce a fracture or dislocation. One experimental treatment, therapeutic hypothermia, is used but there is no evidence that it improves outcomes. Maintaining mean arterial blood pressures of at least 85 to 90 mmHg using intravenous fluids, transfusion, and vasopressors to ensure adequate blood supply to nerves and prevent damage is another treatment with little evidence of effectiveness.Neurosurgery. 2002;50(3 Suppl):S58-62. Surgery Surgery may also be necessary to remove any bone fragments from the spinal canal and to stabilize the spine. Inflammation can cause further damage to the spinal cord, and patients are sometimes treated with a corticosteroid drug such as methylprednisolone to reduce swelling. The drug is used within 8 hours of the injury. This practice is based on the National Acute Spinal Cord Injury Studies (NASCIS) I and II, though other studies have shown little benefit and concerns about side effects from the drug have changed this practice. A food dye, brilliant blue G, has also been shown to have some effect at reducing inflammation after spinal injury. Steroids High dose methylprednisolone may improve outcomes if given within 6 hours of injury. However, the improvement shown by large trials has been small, and comes at a cost of increased risk of serious infection or sepsis due to the immunosuppressive qualities of high-dose corticosteroids. Rehabilitation When treating a patient with a SCI, repairing the damage created by injury is the ultimate goal. By using a variety of treatments, greater improvements are achieved, and, therefore, treatment should not be limited to one method. Furthermore, increasing activity will increase his/her chances of recovery. The rehabilitation process following a spinal cord injury typically begins in the acute care setting. Physical therapists, occupational therapists, social workers, psychologists and other health care professionals typically work as a team under the coordination of a physiatrist to decide on goals with the patient and develop a plan of discharge that is appropriate for the patient’s condition. In the acute phase physical therapists focus on the patient’s respiratory status, prevention of indirect complications (such as pressure sores), maintaining range of motion, and keeping available musculature active. Also, there is great emphasis on airway clearance during this stage of recovery. Following a spinal cord injury, the individual’s respiratory muscles become weak and, in turn, the patient is unable to cough. This results in an accumulation of secretions within the lungs. Physical therapy treatment for airway clearance may include manual percussions and vibrations, postural drainage, respiratory muscle training, and assisted cough techniques. With regards to cough techniques, patients are taught to increase their intra-abdominal pressure by leaning forward to induce cough and clear mild secretions. The quad cough technique is done with the patient lying on their back and the therapist applies pressure on their abdomen in the rhythm of the cough to maximize expiratory flow and mobilize secretions. Manual abdominal compression is another effective technique used to increase expiratory flow which later improves cough. Other techniques used to manage respiratory dysfunction following spinal cord injury include respiratory muscle pacing, abdominal binder, ventilator- assisted speech, and mechanical ventilation. Depending on the Neurological Level of Impairment (NLI), the muscles responsible for expanding the thorax, which facilitate inhalation, may be affected. If the NLI is such that it affects some of the ventilatory muscles, more emphasis will then be placed on the muscles with intact function. For example, the intercostal muscles receive their innervation from T1 - T11, and if any are damaged, more emphasis will need to placed on the unaffected muscles which are innervated from higher levels of the CNS. As SCI patients suffer from reduced total lung capacity and tidal volume it is pertinent that physical therapists teach SCI patients accessory breathing techniques (e.g. apical breathing, glossopharyngeal breathing, etc.) that typically are not taught to healthy individuals. Outcome measures The Functional Independence Measure (FIM) is an assessment tool that aims to evaluate the functional status of patients throughout the rehabilitation process following a stroke, traumatic brain injury, spinal cord injury or cancer. Its area of use can include skilled nursing facilities and hospitals aimed at acute, sub-acute and rehabilitation care. It serves as a consistent data collection tool for the comparison of rehabilitation outcomes across the health care continuum. Furthermore, it aims to allow clinicians to track changes in the functional status of patients from the onset of rehab care through discharge and follow-up. The FIM’s assessment of degree of disability depends on the patient’s score in 18 categories, focusing on motor and cognitive function. Each category or item is rated on a 7-point scale (1 = <25% independence; total assistance required, 7 = 100% independence). As such, FIM scores may be interpreted to indicate level of independence or level of burden of care. Prognosis Spinal cord injuries frequently result in at least some incurable impairment even with the best possible treatment. In general, patients with complete injuries recover very little lost function and patients with incomplete injuries have more hope of recovery. Some patients that are initially assessed as having complete injuries are later reclassified as having incomplete injuries. Recovery is typically quickest during the first six months, with very few patients experiencing any substantial recovery more than nine months after the injury. Tetraplegia (quadriplegia) The ASIA motor score (AMS) is a 100 point score based on ten pairs of muscles each given a five point rating. A person with no injury should score 100. In complete tetraplegia, a recovery of nine points on this scale is average regardless of where the patient starts. Patients with higher levels of injury will typically have lower starting scores. In incomplete tetraplegia, 46 percent of patients were able to walk one year after injury, though they may require assistance such as crutches and braces. These patients had similar recovery in muscles of the upper and lower body. Patients who had pinprick sensation in the sacral dermatomes such as the anus recovered better than patients that could only sense a light touch. Paraplegia In one study on 142 individuals after one year of complete paraplegia, none of the patients where the initial injury was above the ninth thoracic vertebra (T9) were able to recover completely. Less than half, 38 percent, of the studied subjects had any sort of recovery. Very few, five percent, recovered enough function to walk, and those required crutches and other assistive devices, and all of them had injuries below T11. A few of the patients, four percent, had what were originally classified as complete injuries and were reassessed as having incomplete injuries, but only half of that four percent regained bowel and bladder control. Of the 54 patients in the same study with incomplete paraplegia 76 percent were able to walk with assistance after one year. On average, patients improved 12 points on the 50 point lower extremity motor score (LEMS) scale. The amount of improvement was not dependent on the location of the injury, but patients with higher injuries had lower initial motor scores and correspondingly lower final motor scores. A LEMS of 50 is normal, and scores of 30 or higher typically predict ability to walk. Epidemiology Spinal injury can occur without trauma. Many people suffer transient loss of function ("stingers") in sports accidents or pain in "whiplash" of the neck without neurological loss and relatively few of these suffer spinal cord injury sufficient to warrant hospitalization. The prevalence of spinal cord injury is not well known in many large countries. In some countries, such as Sweden and Iceland, registries are available. In the United States, the incidence of spinal cord injury has been estimated to be about 40 cases (per 1 million people) per year or around 12,000 cases per year. The most common causes of spinal cord injury are motor vehicle accidents, falls, violence and sports injuries. The average age at the time of injury has slowly increased from a reported 29 years of age in the mid-1970s to a current average of around 40. Over 80% of the spinal injuries reported to a major national database occurred in males. In the United States there are around 250,000 individuals living with spinal cord injuries. In China, the incidence of spinal cord injury is approximately 60,000 per year. Research directions Scientists are investigating many promising avenues for treatment of spinal cord injury. Numerous articles in the medical literature describe research, mostly in animal models, aimed at reducing the paralyzing effects of injury and promoting regrowth of functional nerve fibers. Despite the devastating effects of the condition, commercial funding for research investigating a cure after spinal cord injury is limited, partially due to the small size of the population of potential beneficiaries. Some experimental treatments, such as systemic hypothermia, have been performed in isolated cases in order draw attention to the need for further preclinical and clinical studies to help clarify the role of hypothermia in acute spinal cord injury. Despite the limitation on funding, a number of experimental treatments such as local spine cooling and oscillating field stimulation have reached controlled human trials, Advances in identification of an effective therapeutic target after spinal cord injury have been newsworthy, and considerable media attention is often drawn towards new developments in this area. However, aside from methylprednisolone, none of these developments have reached even limited use in the clinical care of human spinal cord injury in the U.S. . Stem cells Around the world, proprietary centers offering stem cell transplants and treatment with neuroregenerative substances are fueled by glowing testimonial reports of neurological improvement. It is also evident that when stem cells are injected in the area of damage in the spinal cord, they secrete neurotrophic factors, and these neurotrophic factors help neurons and vessels grow, thus helping repair the damage. Bone Marrow Stem cells especially the CD34+ cells have been found to be relatively more in men compared to women in the reproductive age group among spinal cord injury patients. In 2009 the FDA approved the country's first human trial on embryonic stem cell transplantation into patients suffering from varying levels of traumatic spinal cord injury."FDA Approves a Stem Cell Trial"". The New York Times. Andrew Pollack. January 23, 2009. The trial however came to a halt in November 2011 when the company, which was financing the trial, announced the discontinuation of the trial due to financial issues. It is important to note that only financial issues led to the trial being discontinued and not any scientific or ethical reasons. Other than stem cells, transplantation of tissues such as olfactory ensheathing mucosa have been shown to produce beneficial effects in spinal cord injured rats. Independent validation of the results of the various stem cell treatments is lacking. Fehlings, M. G. and R. Vawda (2011). "Cellular treatments for spinal cord injury: the time is right for clinical trials." Neurotherapeutics 8(4): 704-720.Dobkin, BH.; Curt, A.; Guest, J. "Cellular transplants in China: observational study from the largest human experiment in chronic spinal cord injury." Neurorehabilitation and Neural Repair, v. 20 issue 1, 2006, p. 5-13. However, the right approach on Cell and Tissue based therapies' Clinical application for Spinal cord Injury would be to take a stand on the patients and Clinicians part that any cell or tissue source whose safety has been established could be considered for Clinical applications and continuous efforts must be undertaken to establish the efficacy and mechanisms. BCI Recent research shows that combining Brain–computer interface and Functional electrical stimulation can restore voluntary control of paralysed muscles. A studyC. Ethier, E. R. Oby, M. J. Bauman, L. E. Miller: Restoration of grasp following paralysis through brain-controlled stimulation of muscles. Nature, April 2012. using a monkey as a subject shows that it is possible to directly use commands from the brain, bypass the spinal cord and enable hand function. See also *Central nervous system disorders *Hemiplegia *Neuromuscular disorders *Paralysis *Paraplegia *Quadriplegia *Spinal column References External links * * Cochrane Injuries Group, systematic reviews on the prevention, treatment and rehabilitation of traumatic injury] * Spinal Cord Infarction: Lamination of Fibers *Miami Project to Cure Paralysis Noted for experimental cooling protocol used on Kevin Everett *United Spinal Association A membership organization dedicated to improving the quality of life of individuals with spinal cord injuries and related disorders. *Rehabilitation Research and Training Center (RRTC) on Spinal Cord Injury: Promoting Health and Preventing Complications through Exercise *CareCure Forums- Dr. Wise Young's SCI Forum *SCI Images - Images of Spinal Cord Injury *http://sci.rutgers.edu/index.php?page=viewarticle&afile=24_June_2003@SpinalLevels.html- Spinal Cord Injury Levels and Classification *Spinal Cord Injury Peer Support Patient, Carer and Spouse Support *http://keck.rutgers.edu/main.html The Spinal Cord Injury Project, W.M. Keck Center for Collaborative Neuroscience at Rutgers University *EMSCI Network European Multicenter Study about Spinal Cord Injury *Brigham and Women's Hospital Translational Pain Research Clinical trials for pain following SCI *Pediatric and Adolescent Spinal Cord Injury *Rehabilitation Engineering Research Center on Wheeled Mobility *Spinal Cord Injury Forums SCI Support Forums *International Institute for Research in Paraplegia Research funding foundation, based in Zurich *Spinal Cord Injuries Emergency Medicine for Spinal Cord Injuries * Trefethen, Tre. User's Manual for the Paralyzed Penis: Love after spinal cord injury American Sexuality Magazine. Accessed 3-22-07. *About Spinal Cord Injury Spinal Cord Injury FAQ for those with SCI, and their families, by Canadian Paraplegic Assocation - Ontario. Category:Central nervous system disorders Category:Injuries Category:Medical emergencies Category:Neurotrauma Category:Spinal cord